Psychometric properties of Nepalese preschool anxiety scale among preschool children: A cross‐sectional study

Abstract Background The Preschool Anxiety Scale (PAS)‐Parent version scale is a 28‐item measure designed to assess anxiety symptoms in preschoolers aged 3−6 years. The aim of this study was to assess the psychometric properties of the Nepali translated version of the PAS‐Parent version. Methods A descriptive cross‐sectional design was used to collect data from 680 mothers among seven conveniently selected schools in Kathmandu. Results The difference in PAS‐Parent version scores across age groups was found to be statistically significant. In confirmatory factor analysis, 28 items showed a poor fit of the five‐factor original model for the data. However, removing three items (25 item version) through the five‐factor model indicated a better fit. Internal consistency measured by Cronbach's α for the PAS‐Parent version scale was of good range (0.87). Cronbach's α of the subscales: generalized anxiety (0.63), social phobia (0.67), physical injury fears (0.75), and separation anxiety (0.63) were in fair range; while it was in poor range for the obsessive‐compulsive subscale (0.567). Conclusion Nepali version of the PAS demonstrated fair psychometric properties, supporting its utility in screening and assessing a broad range of anxiety symptoms in Nepalese preschoolers.

Anxiety disorders are the most common class of mental disorders across development. 6,7 and the median age of onset was found to be 6 years for affected youth. 8 Hence this disorder begins very early in life with the prevalence around 9% in preschool population. 9 Anxiety disorder studies have shown concerning stability over preschool period indicating that 34% of children with an anxiety disorder at age 3 continue to meet criteria for diagnosis until age 6. 10 In longer-term, childhood anxiety disorder often follows a chronic or recurring course into adolescence and adulthood. 11 In addition, the prevalence of anxiety disorders in preschool-aged children is similar to children aged 5−17 years. 9 Likewise, anxiety disorder may also predict externalizing and internalizing childhood disorders such as depression and conduct disorder which may occur later in life. 11 Anxiety is another key characteristic of the behaviorally inhibited child. Anxiety disorders in children are common and affects about 5% −17% of children. 12 If the behavioral inhibition is long been implicated in development of internalizing problem children experience anxiety related somatic symptoms, stomach pain, sleeplessness, enuresis, constipation, allergies, and asthma. 13 This behavioral inhibition will lead to shyness and social withdrawal in later life. The characteristic manifests differently in different development ages: inhibited toddlers react to novelty with agitation, distress as well as clinging to the caregiver; preschoolers react with hesitancy, inhibited spontaneous conversation, and school children manifest inhibition through extreme shyness and constriction with unfamiliar adults, and through quiet isolation with unfamiliar peers.
Subsequently in adolescents frequently express behavioral inhibition through social withdrawal, social phobia, and in some instances aggression and violence. 13 This leads to loss in productivity, school absenteeism and more functional impairment as child grow older.
Hence, ability to detect psychiatric disorder early is important. 14 There is a lack of study and human resources working specifically on mental health and anxiety among preschoolers in Nepal. One of the barriers to research into preschool anxiety is the lack of reliable and valid assessment tools. There are relatively little research about anxiety problem among preschooler. 15 The importance of developing adequate strategies for assessing and treating anxiety disorders in preschool-aged children is important to carry out.
The Preschool Anxiety Scale (PAS) is the only measure that specifically assesses multiple anxiety symptoms in preschool-aged children. 16 The PAS is 28-item parent report measure that was designed to assess anxiety dimension specified in Diagnostic and Statistical Manual of Mental Disorders-IV. 16 The factor structure and construct validity of PAS were examined in a large Australian community sample. 16 Confirmatory factor analysis showed five factors: separation anxiety disorder, physical injury fears (PIFs), social phobia, obsessive-compulsive disorder and generalized anxiety disorder (GAD). Anxiety scores were generally higher than the ones reported by Spence. 17 Symptoms of PIFs and social anxiety were the most common, but had found limited evidence for gender or age differences. The PAS scale shows good reliability and construct validity in community scale of children 3−5 years.
In other countries such as Chinese, 17 Dutch, 18 Romanian, 19 Spanish 20 children, being the original five-factor structure proposed by Spence 16 shows good psychometric properties of PAS. A different structure with a five factor model that excluded separation anxiety factor and representing PIF has been found in a Dutch sample. 18 Likewise, in Spanish sample while conducting confirmatory factor analysis (CFA) of five factor model original model, 8 items were eliminated because of their low correlation item scale such as separation anxiety (3 items), social anxiety (4 items) and generalized anxiety (1 items). 21 The purpose of this study was to test the psychometric properties of the Spence PASs. 16 Therefore, this study intended to examine the psychometric properties of the Nepali translated version of PAS-Parent version in private schools of Kathmandu. Internal consistency of the total scale and subscale was assessed.

| Study context
The current population of Nepal is 29,192,480 as per the 2021 census.
The population growth rate is 0.93% per year. In the 2011 census, Nepal's population was approximately 26 million people with a population growth rate of 1.35% and a median age of (21.6 years).
The demographic statistics castes/ethnics group of Nepal is Chhetri

| Study participants
The sample consisted of 680 children (379 boys and 301 girls) aged between 3 and 6 years. The age distribution was as follows: 15.29% (n = 104) were 3 years old; 22.2% (n = 151) were 4 years old; 27.79% (n = 189) were 5 years old and 34.70% (n = 236) were 6 years old. For collecting data, the assessment instrument was completed by their mother (n = 680). They were recruited from six schools in Kathmandu valley of Nepal.

| Sampling method
The schools were selected using convenient sampling method. Most of the participants were in age groups of 26−30 years (36.3%) where as the least number of participants (0.3%) were representing the age group of (15−20) years. About, 27.9% of the mothers reported that they were literate without formal education and only 8.6% had education till master level. The majority of the participants were housewives (45.2%) and the least number of participants (3.7%) held government jobs. The majority of participants were from joint families (52.9%). Only 7.79% of the mothers reported having a history of mental illness in their family.

| Sample size
The sample size has been determined as per the requirement for factor analysis. Several authors have mentioned about criteria of samples in relation to number of items in the questionnaire. For instance, 3:1, 6:1, 10:1, 15:1, or 20:1. [22][23][24] For current study, 20:1 was taken as per rule of thumb; therefore, as there were 34 questions in the PAS the minimum sample size was 680 in this study. Thus, the required mother's sample was 680 for confirmatory factor analysis.
To reach this sample size, 800 participants were approached among which 120 did not agree to participate in the study leading to the response rate of 85% in this study.

| PAS
The PAS originally is comprised of 34 items. During assessment, among the preschool children the mothers reported that there was no any PTSD symptoms so we removed 6 items from PAS. Likewise, the PTSD symptoms were not include in factor analysis because there is no occurrence of traumatic events in preschooler. 4 The PAS is comprised of 28 items providing information about anxiety and worries in children from 3 to 6 years. The PAS-parent version consists of five subscales: social anxiety disorder, PIFs, social phobia, obsessive-compulsive disorder, and GAD, post-traumatic stress disorder. The participants were asked to rate the items of each subscale on a 5-point scale ranging from 0 (not true at all) to 4 (very often true). Construct validity of the scale was good. 16 The permission to utilize the tool was obtained from the lead author. 16 The PAS was translated into Nepali by a bilingual, mental health expert in psychology, teacher and profession by clinical background. The translated version of the tool (Nepali version) was reviewed by three clinical psychologists from Tribhuvan University Teaching (TUTH). It was followed by back translation of the Nepali tool into English by a bilingual anthropology expert. To study the discrepancies, the two English copies were compared by the researchers and two mental health experts and found that there was no discrepancy in the content and meaning of the items of the tool; hence, the Nepali version of the tool was found to be equivalent and relevant to be pretested among the study participants. Preschooler children were considered eligible for the study if they were 3−6 years old and their mother who were willing to participate.
A sealed envelope containing a request letter to parents, an informed consent form, and Nepali version of the PAS were sent to parents through the school authority. The questionnaires returned by parents were collected from the school administration. Mean Square Residual value is less than 0.06. 26

| RESULTS
The finding showed that total PAS (mother) score was significantly associated with mother education (p < 0.007), mothers' occupation (p < 0.001), family types (p < 0.003), Caste (p < 0.004). Similarly, the total PAS score (Preschool children) significantly associated with age of children (p < 0.033) and sex (p < 0.01).  Table 1. anxieties were also associated with child anxiety. Similarly, insecure attachment and behavioral inhibition can be associated with child anxiety. Likewise, the highest levels of anxiety were shown by children who were behaviorally inhibited and insecurely attached and whose mothers were also anxious. 27 Children with secure attachments from parents and teachers showed higher reaction time and better auditory, visual, and visual spatial selectivity and maintenance. 28 T A B L E 1 Confirmatory factor analysis of PAS (mother) The score of PAS was found to differ significantly across sex in this study. However, some studies 29  Obsessive-compulsive disorder has poor internal consistency, (0.56).

| CONCLUSION
The Nepalese version of the PAS demonstrated to have good psychometric properties in a sample of three to 6-year-old children.
Age and sex differences across PAS scales were found to be The PAS could be considered as a potential instrument to screen and assess the type and severity of anxiety problems. Moreover, it can also be a good supporting tool for clinicians and researchers, as it is short and easy to administer.

ACKNOWLEDGMENT
The author(s) received funding of USD 849 from University Grants Nepal which was used to pay the fees to experts during translation, review phase and printing (Mphil-75/76-HS-3).

CONFLICT OF INTEREST
The authors declare no conflicts of interest.

TRANSPARENCY STATEMENT
The lead author Sabina Maharjan affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.